HIV Infection and Pregnancy Status Among Adults Attending Voluntary Counseling and Testing in Two Developing Countries

From CDC National Prevention Information Network

December 9, 2002

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The effect of an HIV diagnosis on reproduction planning in developing countries is not well understood. Clinical symptoms of disease, coexisting sexually transmitted infections, and HIV-induced amenorrhea are associated with reduced fertility. HIV infection may also result in pregnancy complications such as decreased birthweight, prematurity, and elevated risk of preterm delivery. Psychosocial factors also affect reproduction planning and fertility among individuals infected with HIV, both in developed and developing countries.

Many studies lack consideration of the effect of intention to bear offspring on reproduction following HIV diagnosis. In developed countries, HIV diagnosis appears to lead many women to avoid pregnancy or to undergo pregnancy termination, decisions that may be attributed in part to availability of and access to voluntary counseling and testing (VCT), modern contraception, and safe and legal abortion services. By contrast, studies in several African countries have suggested that HIV diagnosis has little effect on subsequent childbearing. Yet, one limitation of these studies is that none have directly examined the effect of intention to reproduce on reproduction following HIV diagnosis.

The authors examined the association of intention to bear children and knowledge of HIV serostatus with subsequent reproductive behavior among men and women receiving HIV voluntary counseling and testing in Kenya and Tanzania. In addition to providing descriptive analyses, the authors tested the direct and interactive effects of HIV serostatus and intention to reproduce on pregnancy status 6 months post-VCT. Assuming that the desire to avoid vertical transmission would outweigh contextual factors favoring reproduction among infected individuals, the authors hypothesized that participants diagnosed with HIV infection who also reported intention to reproduce before learning their serostatus would be less likely than uninfected participants to be pregnant or to have a pregnant partner 6 months post-VCT.

All participants included in this analysis were drawn from the Voluntary HIV Counseling and Testing Efficacy Study, a randomized controlled trial evaluating the efficacy of VCT in changing sexual risk behavior among adults in Nairobi, Kenya, and Dar es Salaam, Tanzania. The target study population included individuals and couples seeking HIV-related services in an urban public hospital in Dar es Salaam and a free-standing clinic in a low-income suburban settlement in Nairobi.

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The study involved a longitudinal design with assessments at baseline (time 1), 6 months post-VCT (time 2), and 12-month follow-up (time 3). Participants were randomized to 1 of 2 conditions: an ideographic VCT intervention designed to facilitate HIV risk behavior change, or a comparison condition in which participants received general health information relevant to HIV. At time 2, participants in the comparison group received the VCT intervention, such that by time 3 all participants had received VCT when they returned for assessment. Given that the focus of this study was pregnancy status within 6 months of HIV serotesting, only data corresponding to pre (baseline) and post-VCT (follow-up) assessments were used for this study. Only participants unaware of their HIV serostatus at screening were eligible to enroll in the study.

There were 2,942 eligible participants for primary data analysis. The authors then excluded participants based on sexual abstinence, being pregnant, men 60 years or older, women 40 years or older, same sex partners and women with a history of tubal ligation, leaving 1,634 eligible participants for secondary analysis.

The authors found that women who were younger, not using contraception, aware of the risk of vertical transmission, and HIV infected were more likely than those with the opposite characteristics to be pregnant at time 2. Although pregnancy planning showed no main effect on pregnancy status for women, fewer of those who tested negative reported a pregnancy at 6 months post-VCT.

Taken together, these findings suggest that diagnosis with HIV may have precipitated a reduction in fertility among less healthy women, independent of the effects of relationship status, number of children, and frequency of sexual activity. Men who were younger, married or cohabitating, not using contraception, and aware of risks of vertical transmission were more likely to report that their partners were pregnant at 6 months post-VCT, regardless of their HIV serostatus. The latter findings suggest that men's awareness of their HIV serostatus and baseline intention to reproduce were unrelated to partner pregnancies reported 6 months later.

"HIV diagnosis may influence reproduction planning for women but not for men," the authors wrote. "Future VCT intervention research would do well to tailor protocols to appeal to men and increase their participation, incorporate family planning issues in VCT programming (including alternatives to child-bearing), and enhance VCT messages to appeal to participants' desire to ensure the well-being of their offspring."

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